Poliomyelitis By: Dr. Masoud Shayesteh Azar Associate Professor, Orthopaedic Department, Mazandaran University

Poliomyelitis polio= gray matter Myelitis= inflammation of the spinal cord

Poliomyelitis First described by Michael Underwood in 1789 First outbreak described in U.S. in 1843 21,000 paralytic cases reported in the U. S. in 1952 Global eradication in near future 4

Poliomyelitis Poliomyelitis, literally meaning “gray spinal cord inflammation It is a viral infection There are three types of poliovirus and many strains of each type It is contagious: usually spread from person to person. Only harmful to humans

The Poliovirus Virus localized in the anterior horn cells of the spinal cord and certain brain steam motor nuclei.

Poliovirus Enterovirus (RNA) Three serotypes: 1, 2, 3 Minimal heterotypic immunity between serotypes Rapidly inactivated by heat, formaldehyde, chlorine, ultraviolet light

Poliomyelitis Pathogenesis Entry into mouth Replication in pharynx, GI tract, local lymphatics Hematologic spread to lymphatics and central nervous system Viral spread along nerve fibers Destruction of motor neurons

Poliomyelitis Pathogenesis The ant. Horn motor cells may be damaged by viral multiplication or toxic byproducts of the virus or indirectly by ischemia, edema, and hemorrhage in the glial tissues. Destruction of the spinal cord occurs focally and within 3 days wallerian degeneration is evident.

poliomyelitis Most affects children under the age of 5 years in developing tropical countries. Incubation period ranges from 6 to 20 days

What are the symptoms? Acute stage: generally lasts 7 to 10 days. Many include fever, pharyngitis, headache, anorexia, nausea, and vomiting. Illness may progress to aseptic meningitis and menigoencephalitis in 1% to 4% of patients. These patients develop a higher fever & sever headache with stiffness of the neck and back.

What are the symptoms? Paralytic disease occurs 0.1% to 1% of those who become infected with the polio virus. Paralysis of the respiratory muscles or from cardiac arrest if the neurons in the medulla oblongata are destroyed.

Clinical course Symptoms range :from mild malaise to generalized encephalomyelitis with widespread paralysis. Hyperesthesia or paresthesia in the extremities and muscular pain is common. Muscles are tender even to gentle palpation.

Poliomyelitis According to Sharrard, weakness is clinically detectable only when more than 60% of the nerve cells supplying the muscle have been destroyed. Paralysis occurs twice as often in the lower extremity as in upper extremity.

Poliomyelitis The most commonly affected muscles are the Quadriceps, glutei, tibialis anterior, medial hamstrings, and hip flexors. Deltoid, triceps, and pectoralis major.

Poliomyelitis Patients have some or full recovery from paralysis, most clinical recovery occurs during the 1 month and almost complete within 6 months. Limited recovery may occur for about 2 years.

Poliomyelitis In cases with paralysis superficial reflexes usually are absent first, and deep tendon reflexes disappear when the muscle group is paralyzed. DDX.: Guillain-Barre syndrome, and other forms of encephalomyelitis

Treatment in the acute stage Bed rest, analgesics, hot packs, and anatomical positioning of the limbs gentle passive ROM exercises of all joints

Treatment in the acute stage close monitoring of respiratory and cardiovascular functioning is essential during the acute stage of poliomyelitis along with fever control and pain relievers for muscle spasms. Mechanical ventilation, respiratory therapy may be needed depending of the severity of patients.

Convalescent stage From 2 days after the temperature return to normal and continues for 2 years Muscle power improves Physical therapy is recommended for full recovery. Passive stretching exercises and wedging casts can be used for mild to moderate contractures.

Convalescent stage Surgical release of tight fascia and muscle aponeuroses and lengthening of tendons may be necessary for contractures persisting longer than 6 months. Orthoses should be used until no further recovery is anticipated.

Chronic stage 24 months after the active illness: The goals of treatment include correcting any significant muscle imbalance and preventing or correcting soft tissue or bony deformities.

Chronic stage Static joint instability can be controlled by Orthoses. Dynamic joint instability result in a fixed deformity that cannot be controlled by Orthoses.

Chronic stage Soft tissue surgery, such as tendon transfers, should be done in young children before the development of any fixed bony changes. Bony procedures for correcting a deformity can be delayed until skeletal growth is near completion.

Global eradication in near future Prevention Immunization of the young continues

Wild Poliovirus 1988 National Immunization Program Centers for Disease Control and Prevention

Wild Poliovirus 2004 Centers for Disease Control and Prevention National Immunization Program National Immunization Program Centers for Disease Control and Prevention National Immunization Program Centers for Disease Control and Prevention

Study We study 246 patient with polio in Sari Male:156 cases (63/4%) female: 90 cases (36/6%) age :22 to 63 years old main age 46/3 One lower limb: 164 cases (66/6%) Both lower limb: 62 cases (25/2 %) Both lower limb together with upper limb 10 cases (4/1% )

Result: From 246 patients ;108 used brace 56 patients needs brace but not used 187 operation has down for these patients 97 patients more than one operation has down 82 patients have mild symptoms and don’t need To any operation or brace.

Result: From 187 operation : 53 cases; ankle triple arthrodesis 81 cases; tendon transfer EHL to dorsum foot 10 cases; other kind of tendon transfers 11 cases; ATL 8 cases; lower limb lengthening

Result: 2 cases; Ephypisodesis 1 case; ankle fusion 23 cases; toe deformity correction 53 cases; soft tissue release for knee and hip flexion contracture 37 cases; osteotomy around knee

Result: Very important point No any new case in last 10 years reported.